Aripiprazole Treatment in Delusional Infestation: Resolving Atypical Presentations of Body Fluid Leakage

Introduction

Delusional infestation, also known as delusional parasitosis or Ekbom syndrome, is a rare psychiatric condition marked by persistent delusions of infestation with parasites or other unseen organisms, despite a lack of objective evidence [1]. Patients often present with skin lesions, intense itching, and burning sensations, frequently leading to self-inflicted excoriations [2]. Delusional infestation predominantly affects middle-aged women and poses a diagnostic challenge, as patients often resist a psychiatric diagnosis, leading to multiple medical consultations and potential misdiagnosis [3]. This frequently results in underestimation and undertreatment of the disorder.

While typical delusional infestation involves delusions of parasitic infestation, atypical presentations involving delusions of infectious body fluid leakage have been reported, although less frequently. While specific prevalence data are limited, anecdotal reports and case series suggest that delusions of bodily fluid leakage, while uncommon, are a recognized variant of delusional infestation. Further research is needed to quantify the prevalence of this specific presentation. This report describes 2 such cases, emphasizing the importance of recognizing this unusual manifestation of delusional infestation. Informed consent was obtained from both patients to publish their findings.

Case Reports

CASE 1:

A 57-year-old woman presented with multiple, longstanding skin lesions on her arms, characterized by erythematous papules, excoriations, and crusts. She reported intense itching and burning, describing a sensation of “dirty body fluids” emanating from the lesions, prompting vigorous scratching. Examination revealed self-inflicted excoriations without evidence of primary skin disease or infestation.

She had consulted numerous specialists, including dermatologists, allergists, and psychiatrists, receiving various diagnoses and treatments for presumed dermatological conditions. Skin biopsy and scrapings obtained from lesional skin with the preliminary diagnosis of scabies was nonspecific. Despite trials of multiple antidepressants (duloxetine, sertraline, paroxetine, escitalopram, citalopram), her symptoms persisted. A detailed psychiatric interview revealed delusions and hallucinations related to her skin lesions. She described crawling sensations and “hearing them yelling to be leaked out”.

Her medical history included hypothyroidism diagnosed more than a decade before, and there was no family history of psychiatric disorders. A complete blood cell count, metabolic panel, and thyroid-stimulating hormone results were within the reference ranges. She had a history of depression and anxiety, diagnosed approximately 5 years prior to the onset of her dermatological symptoms and treated with selective serotonin reuptake inhibitors (SSRIs). She denied substance abuse.

On mental status examination, she was anxious and preoccupied with her skin. Her thought content was dominated by delusional beliefs about infectious body fluid leakage. Her affect was congruent with her delusions, and her thought process was linear and goal-directed. She reported auditory and tactile hallucinations related to the leakage, even in the absence of scratching.

CASE 2:

A 41-year-old woman presented with multiple excoriated lesions on her arms and intense itching. Lesional skin histopathologic findings and perilesional direct immunofluorescence studies had ruled out any bullous disorders. She had been previously diagnosed with dermatitis of unknown cause by dermatologists and treated with various topical and systemic therapies without improvement. She had also seen psychiatrists and received trials of duloxetine, fluoxetine, escitalopram, risperidone, and olanzapine, also without relief. Her medical history included epilepsy since childhood, which was well-controlled with medical treatment. There was no family history of psychiatric disorders, and she denied substance abuse.

Examination revealed excoriated lesions consistent with self-inflicted trauma, with no evidence of primary skin disease. She believed her skin was infested with infections, describing crawling sensations and the perception of fibers or particles emerging from her skin. Her thought content was dominated by these delusions, and she lacked insight into their irrationality. She had a history of depression and anxiety, diagnosed approximately 3 years prior to the onset of her dermatological symptoms and treated with SSRIs.

DIAGNOSIS AND MANAGEMENT:

In both cases, extensive workups, including laboratory tests and skin biopsies, had previously excluded organic causes for the skin lesions. Electroencephalogram and brain magnetic resonance imaging results were normal (Figures 1A, 1B, 2A, 2B). Given the persistent symptoms, despite dermatological interventions and the presence of unusual delusions, a diagnosis of delusional infestation with atypical presentation (delusions of infectious body fluid leakage) was made in both cases.

The patient in case 1 was initiated on aripiprazole 10 mg daily, which was titrated up as needed. The patient in case 2 was also started on aripiprazole, initially at 10 mg and titrated up to 30 mg due to lack of initial response. Both patients demonstrated significant improvement within weeks, with reduced itching, healing of skin lesions, and decreased delusional thinking. Follow-up assessments confirmed sustained improvement and resolution of delusions and hallucinations (Figure 3).

Discussion

These 2 cases highlight the diagnostic challenges posed by atypical presentations of delusional infestation, specifically delusions of infectious body fluid leakage. The patients’ initial presentations, mimicking dermatological conditions, led to delayed psychiatric intervention and prolonged suffering. This underscores the critical importance of considering psychiatric diagnoses, even when dermatological symptoms are prominent and persistent, especially when standard dermatological treatments prove ineffective. The lack of response to dermatological treatments, nonspecific histopathological findings coupled with the presence of unusual delusions related to infectious body fluids, should raise strong suspicion for delusional infestation. The presence of these unusual delusions, particularly those related to infectious body fluids, warrants a thorough psychiatric evaluation.

Delusional infestation is thought to involve dysregulation of the dopaminergic system [4]. While some cases can be secondary to underlying medical conditions (eg, neurological disorders, B12 deficiency) or substance use [5,6], no such contributing factors were identified in our patients. The role of hypothyroidism in case 1 and epilepsy in case 2 can be speculated as organic causes of psychosis; however, the organic diseases of both cases were long-standing and well-controlled with treatment. It is crucial to differentiate between primary delusional infestation and secondary delusional infestation, as management strategies can differ. Approximately 60% of individuals with a diagnosis of delusional infestation have an underlying and often treatable condition that contributes to their symptoms [5,6]. In addition, many patients with delusional infestation have been reported to have multiple psychiatric comorbidities [7].

Clinically, patients typically report an infestation with small and vivid pathogens, such as worms, insects, and “parasites”, and rarely also by bacterial, viral, and fungal microorganisms [7,8]. However, atypical presentations with larger-sized pathogens and environmental infestation were reported, for instance, of a patient who was convinced that her house was infested with rats [8]. Infestations with inanimate objects, such as threads, hair, and fibers, were defined as Morgellons disease [8].

The primary role of the histopathology among investigations of delusional infestation is very limited, as histopathological findings are most commonly consistent with nonspecific dermatitis and excoriations. However, as in our patients, skin biopsies from lesional and perilesional skin can be performed, in order to rule out infestations and bullous dermatoses [9]. Some authors recommend skin biopsy should be performed only if requested by the patient. Repeated biopsies are not recommended [1].

The successful treatment of both patients with aripiprazole further supports the role of antipsychotic medication in managing delusional infestation, including its atypical forms. Antipsychotic medication, particularly dopamine antagonists like aripiprazole, is the mainstay of treatment for delusional infestation [10]. Our cases demonstrate aripiprazole’s efficacy in managing typical and atypical delusional infestation presentations. Aripiprazole’s effectiveness in these cases, despite differing initial presentations and previous treatment failures, suggests its utility in targeting the underlying dopaminergic dysregulation implicated in delusional infestation. The variable dosing requirements (one patient requiring a higher dose) underscore the importance of individualized treatment approaches and careful monitoring for efficacy and potential adverse effects [10]. Cognitive behavioral therapy is generally not considered a first-line treatment for delusional infestation, particularly during acute psychotic episodes, due to the patient’s impaired insight and cognitive state. While cognitive behavioral therapy can be helpful in the recovery phase, to address residual symptoms and improve coping skills, it was not used in these cases, due to the nature of their acute presentations.

These cases have limitations. The small sample size limits the generalizability of the findings. Further research, including larger case series and epidemiological studies, is needed to better understand the prevalence, clinical characteristics, and optimal treatment strategies for atypical delusional infestation presentations, such as delusions of infectious body fluid leakage. Additionally, these cases do not address long-term treatment outcomes or the potential for relapse. Future studies should focus on long-term follow-up and identify factors associated with treatment response and relapse prevention. Furthermore, while these cases highlight the importance of psychiatric evaluation, they do not explore the specific tools or methods that might be most effective in identifying atypical delusions. Future research could investigate the use of structured interviews or other assessment instruments to improve diagnostic accuracy.

Conclusions

These cases provide further evidence supporting the existence of atypical presentations of delusional infestation, specifically delusions of infectious body fluid leakage. They underscore the necessity of maintaining a high index of suspicion for delusional infestation in patients presenting with persistent, unexplained dermatological symptoms, particularly when standard treatments are ineffective. Thorough psychiatric evaluation, including detailed exploration of patients’ sensory experiences and beliefs, is essential for accurate diagnosis. Aripiprazole appears to be an effective treatment for typical and atypical delusional infestation, although individualized dosing can be required. Increased awareness of these atypical presentations among healthcare providers is critical to reducing diagnostic delays and improving patient outcomes. Future research should prioritize determining the prevalence of these atypical presentations, identifying potential risk factors, and optimizing treatment strategies for this challenging condition. Specifically, research should focus on larger studies, long-term follow-up, and the development of standardized assessment tools for atypical delusional infestation.